Running head: PARENT TRAINING FOR PRESCHOOL ADHD 1
Parent training for preschool ADHD: A randomized controlled trial of specialized and
generic programs
Howard B. Abikoff,1 Margaret Thompson,2,3,4 Cathy Laver-Bradbury,3 Nicholas Long,5 Rex L.
Forehand,6 Laurie Miller Brotman,7,1 Rachel G. Klein,1 Philip Reiss,1,7,8 Lan Huo,1 and Edmund
Sonuga-Barke4,9,10
1Department of Child and Adolescent Psychiatry, New York University School of Medicine,
USA; 2Child and Adolescent Mental Health Service, Southampton City PCT, Southampton, UK;
3Orchard Centre, Southampton, UK; 4Department of Psychology, University of Southampton,
UK; 5Department of Pediatrics, University of Arkansas for Medical Sciences, USA; 6Department
of Psychological Science, University of Vermont, USA; 7Department of Population Health, New
York University School of Medicine, USA; 8Nathan S. Kline Institute for Psychiatric Research,
USA; 9Department of Experimental Clinical and Health Psychology, Ghent University, BE;
10Department of Child Psychiatry, Aarhus University, DK
Conflicts of interest: Howard B. Abikoff, Laurie Miller Brotman, Rachel Klein, Philip Reiss and
Lan Huo have no conflict of interests to report. Margaret Thompson has research grants from
NIHR, Solent NHS Trust, European Union (ADDUCE), an MHRN unrestricted research grant
from Shire, conference sponsorship from Eunethydis, is a co-developer of the New Forest
Parenting package (NFPP), and receives dividends from the sale of the NFPP self-help manual.
Cathy Laver-Bradbury has been on the advisory board of several pharmaceutical companies and
is a co-developer of the NFPP. Nicholas Long receives royalties from the book “Parenting the
Strong Willed Child”, a derivative of “Helping the Noncompliant Child” (HNC). Rex L
Forehand has an NIMH grant investigating the use of technology to enhance HNC and receives
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 1
royalties from the sale of HNC and from “Parenting the Strong Willed Child”. Edmund Sonuga-
Barke declares the following competing interests during the last three years – fees for speaking,
consultancy, research funding and conference support from Shire; speaker fees from Janssen
Cilag, Medice & Obtech, book royalties from OUP and Jessica Kingsley; conference support
from Shire.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 2
Abstract
Background: The “New Forest Parenting Package” (NFPP), an 8-week home-based intervention
for parents of preschoolers with ADHD, fosters constructive parenting to target ADHD-related
dysfunctions in attention and impulse control. Although NFPP has improved parent and
laboratory measures of ADHD in community samples of children with ADHD-like problems, its
efficacy in a clinical sample, and relative to an active treatment comparator, is unknown. Aims:
Aims are to evaluate the short and long-term efficacy and generalization effects of NFPP
compared to an established clinic-based parenting intervention for treating noncompliant
behavior (“Helping the Noncompliant Child” [HNC]) in young children with ADHD. Design:
Randomized controlled trial with three parallel arms. Methods: 164 3-4-year-olds, 73.8% male,
meeting DSM-IV ADHD diagnostic criteria were randomized to NFPP (N = 67), HNC (N = 63),
or wait-list control (WL, N = 34). All participants were assessed at post-treatment. NFPP and
HNC participants were assessed at follow-up in the next school year. Primary outcomes were
ADHD ratings by teachers blind to and uninvolved in treatment, and by parents. Secondary
ADHD outcomes included clinician assessments, and laboratory measures of on-task behavior
and delay of gratification. Other outcomes included parent and teacher ratings of oppositional
behavior, and parenting measures. (Trial name: Home-Based Parent Training in ADHD
Preschoolers; Registry: ClinicalTrials.gov Identifier: NCT01320098; URL:
http://www/clinicaltrials.gov/ct2/show/NCT01320098). Results: In both treatment groups,
children’s ADHD and ODD behaviors, as well as aspects of parenting, were rated improved by
parents at the end of treatment compared to controls. Most of these gains in the children’s
behavior and in some parenting practices were sustained at follow-up. However, these parent-
reported improvements were not corroborated by teacher ratings or objective observations. NFPP
was not significantly better, and on a few outcomes significantly less effective, than HNC.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 2
Conclusions: The results do not support the claim that NFPP addresses putative dysfunctions
underlying ADHD, bringing about generalized change in ADHD, and its underpinning self-
regulatory processes. The findings support documented difficulties in achieving generalization
across non-targeted settings, and the importance of using blinded measures to provide
meaningful assessments of treatment effects.
Keywords: ADHD, preschool, parent training, generalization
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 3
Attention-deficit/hyperactivity disorder (ADHD) affects individuals across the life span
and onset is typically during the preschool years (Sonuga-Barke & Halperin, 2010). Preschool
ADHD, which shares the symptom structure and core clinical features of ADHD in later
childhood (Greenhill, Posner, Vaughan & Kratochvil, 2008), is often associated with problematic
family interactions (Daley, Sonuga-Barke, & Thompson, 2003) that contribute to high levels of
familial stress and mental health problems (DeWolfe, Byrne, & Bawden, 2000). Longitudinal
studies highlight the relative stability of ADHD from preschool to school age, especially in
clinical samples (Riddle et al., 2013), although subtype designation varies considerably over time
(Lahey, Pelham, Loney, Lee, & Willcutt, 2005).
Effective interventions for ADHD in early childhood are needed – both to reduce
impairment during the preschool period itself, and as strategies that may alter the disorder’s
longer-term trajectory. Randomized controlled trials support the value of stimulant treatment,
although effects on core ADHD symptoms and functional outcomes may be smaller and less
consistent than in older children and side effects more frequent (Abikoff et al., 2007; Greenhill et
al., 2006). Because of resistance to medicating young children (Volkow & Insel 2003), the
development of effective non-pharmacological treatments for preschoolers represents an
important health policy objective. Indeed, the preschool period may be especially favorable to
target ADHD with psychosocial approaches, given neurodevelopmental evidence for early life
brain plasticity and the fact that the coercive cycles of parent-child interactions characteristic of
ADHD may not yet be firmly established, and therefore easier to alter than in later childhood
(Sonuga-Barke, Thompson, Abikoff, Klein, & Brotman, 2006). This possibility is consistent with
two recent meta-analyses. Charach et al.’s (2013) review concluded that there was evidence for
the value of parent training for preschool ADHD. Sonuga-Barke et al. (2013) reported that trials
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 4
with preschoolers had the largest effect sizes for behavioral interventions, albeit on outcome
measures completed by raters aware of and involved in treatment.
Parent training approaches used in preschool ADHD, generally referred to as behavioral
parent training (BPT), typically apply principles of positive and negative reinforcement to teach
parents behavioral strategies to manage conduct problems, especially noncompliance and
oppositionality. Examples include Webster-Stratton’s “Incredible Years” (Webster-Stratton,
Reid, & Beauchraine, 2011) and Sanders’ “Triple P” (Bor, Sanders, & Markie-Dadds, 2002).
BPT yields improvements in oppositional and disruptive behaviors, and enhances parenting skills
(Charach et al., 2013). However, improvements in ADHD symptoms are less common and
robust (Charach et al, 2013; Rajwan, Chacko, & Moeller, 2012). The common expectation that
BPTs are indicated for ADHD symptoms has been attributed to the questionable (and often
implicit) assumption that these symptoms will be as responsive as conduct problems to the
modification of environmental contingencies through the effective use of rewards and
punishments (Sonuga-Barke et al., 2006).
In contrast to BPT, the New Forest Parenting Package (NFPP; Thompson et al., 2009)
was developed specifically to treat ADHD in preschool children. NFPP, an 8-week home-
delivered intervention, combines behavior management techniques with procedures intended to
foster constructive parenting to target impairments in underlying processes, including self-
regulation, attention, impulse control, and working memory, which ostensibly lead to ADHD
symptoms in young children. Parents are taught to take on the role of skilled tutor to create
occasions and settings within a positive emotional climate that promote reciprocal, sensitive,
positive and playful parent-child interactions, and to use scaffolding to facilitate the development
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 5
of self-regulation in young children (Wacharasin, Barnard, & Spieker, 2003; Connell & Prinz,
2002).
The first study of NFPP (Sonuga-Barke, Daley, Thompson, Laver-Bradbury, & Weeks,
2001), delivered by highly skilled nurse therapists, compared it to an active attention control
(Parent Counseling and Support), and a wait-list control, in a community-based sample of three-
year-old children with ADHD-type problems. Compared to both control groups, NFPP yielded
clinically significant reductions in parent-reported ADHD symptoms and conduct problems
(oppositional, defiant behaviors), increases in observed on-task behavior, and improved maternal
sense of well-being. The improvements in ADHD symptoms were in the range found with
stimulants in preschoolers (Greenhill et. al., 2006) and persisted to 15 weeks follow-up. A
second controlled study found no evidence of efficacy when NFPP was delivered by non-
specialist primary care nurses (Sonuga-Barke, Thompson, Daley, & Laver-Bradbury, 2004).
During the course of the current study, a small-scale trial of NFPP (revised to enhance the
treatment’s constructive parenting element) (Thompson et al., 2009), provided by trained nurse
specialists to preschoolers meeting ADHD rating-scale criteria, replicated some of the initial
NFPP findings. Improvements in parent-reported ADHD symptoms were confirmed and were
sustained at 7 weeks follow-up. Conduct problems improved based on parental interview, but
not on parent ratings. Treatment effects on on-task behavior and maternal well-being were not
replicated, and there was no improvement in the observed quality of parent-child interactions.
While these trials suggest the potential efficacy of NFPP in improving ADHD symptoms
in preschoolers, they had important limitations. First, although the children in these community
samples met recognized cut-off levels for ADHD on validated instruments, they had not been
diagnosed as having ADHD. Second, generalization to settings outside the home (i.e., school)
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 6
was not tested. Third, NFPP was not compared to BPT, which has typically been recommended
in ADHD guidelines as a cost-effective treatment (American Pediatric Association, 2011;
National Institute for Health and Clinical Excellence [NICE], 2008).
NFPP’s distinctive claim is that it targets core ADHD processes and therefore should
have a greater, more wide-ranging impact on preschool ADHD symptoms than standard BPT.
Evidence supporting this claim would have important clinical implications and provide
justification for choosing this parenting approach in treating preschool ADHD. We addressed
the issue of relative superiority of NFPP by comparing it to a generic parent training program
that has established efficacy in treating oppositional behaviors in young children – problems
common in ADHD: “Helping the Non-Compliant Child” (HNC) (McMahon & Forehand, 2003).
Both HNC and NFPP are delivered on a one-on-one basis and over a similar period, thereby
facilitating a head-to-head comparison. Our goal was to test the specific and nonspecific
therapeutic value of NFPP in clinically-diagnosed three- and four-year-olds with ADHD in an
RCT. The primary aims address NFPP’s effects on children’s ADHD core symptoms relative to
HNC, and to a wait list control (WL), generalization to school settings, and maintenance of
treatment effects over time. Secondary, we tested NFPP’s effects on children’s self-regulatory
and oppositional behaviors and on parenting.
Based on NFPP’s theoretical rationale and prior findings, we predicted that: 1) NFPP
would be superior to both HNC and WL with regard to ADHD symptom reduction, rated by
parents, teachers and clinicians, and by direct observation; 2) positive effects for NFPP, relative
to HNC, would persist during the next school year; 3) NFPP would reduce impulsive choice, and
increase delay tolerance, relative to HNC and WL; and 4) NFPP would show significant
reductions in parent- and teacher-rated oppositional symptoms compared to WL – with no
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 7
specific prediction regarding its relative value compared to HNC on these measures. The trial
also examined treatment effects on parenting; specifically: whether (i) parental responsiveness
and scaffolding improve in NFPP only; and (ii) positive parenting practices and perceived stress
improve in both NFPP and HNC.
Methods
Site
The study was conducted at New York University (NYU) Langone Medical Center
between March 2008 and December 2012. NYU and NYC Department of Education
institutional review boards approved the study. After complete description of the study to
parents, parents provided signed informed consent.
Design
In a three-group parallel design, children were randomly assigned to (a) NFPP, (b) HNC,
or (c) WL. The randomization was stratified by age (3 or 4 years old) and gender. Block
randomization to the three treatment conditions (NFPP, HNC, WL) was in a ratio (2:2:1) and
was carried out in blocks of random sizes (5 or 10). The randomization assignment was computer
generated and automatically linked to a subject when the subject’s data for eligibility were
entered into the database and it was established that s/he met the study entry criteria. The
randomization sequence was generated by the research organization responsible for data
management. Participants were enrolled by research coordinators; eligibility for enrollment was
determined based on exclusion/inclusion criteria which were checked when subjects’ data were
entered into the database. (Trial registry: Home-Based Parent Training in ADHD Preschoolers;
Registration ID, ClinicalTrials.gov Identifier: NCT01320098; URL:
http://www/clinicaltrials.gov/ct2/show/NCT01320098).
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 8
Participants and Procedures
Sample size determination. The sample size was selected to allow at least 80% power
for two-sided tests with significance level 0.05/2=0.025 (to account for conducting 2 tests) to
detect what were deemed, a priori, to be clinically meaningful effects of NFPP against WL and
HNC with respect to the primary outcomes (teacher and parent ADHD ratings). The planned
total sample size of 187 (75:75:37 for NFPP:HNC:WL) allowed detecting differences of
magnitude Cohen’s d= 0.62 to 0.68 (depending on dropout rate, from 0% to 15%) against
WL. Against HNC, this sample size allowed detecting differences of magnitude d=0.51 to
0.55. Lower recruitment (e.g., N=159) would have sufficient power to detect negligibly larger
effects -- d=0.68 to 0.74 against WL and d=0.55 to 0.60 against HNC.
Inclusion criteria. Participants were 3.0 - to 4.11-year-old boys and girls attending a
preschool, daycare or nursery school at least 2 and-a-half days a week. Inclusion required that
the primary caretaker be fluent in English and that the child have an IQ > 70 on the Wechsler
Preschool Primary Scale of Intelligence, 3rd edition (WPPSI-III; Wechsler, 2002); elevated
scores above age and gender norms on the DSM-IV Total, DSM-IV Hyperactive/Impulsive, or
DSM-IV Inattentive subscales on both the Revised Conners Teacher (CTRS-R) (T-score > 65)
and Parent (CPRS-R) Rating Scales (T-score > 60), (Conners, Sitarenios, Parker, & Epstein,
1998a, 1998b); a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV;
American Psychiatric Association, 1994) diagnosis of ADHD (any type) on the Diagnostic
Interview Schedule for Children-Parent Report Version 4, (Shaffer et al., 1998), modified Young
Child Version (DISC-IV-YC) (Lucas, Fisher, & Luby, 1998), confirmed by clinical evaluation
conducted by a psychologist with child and parent; standard score > 7 on the Concepts and
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 9
Following Directions subscale of the Clinical Evaluation of Language Fundamentals (CELF-2,
Semel, Wiig, & Secord, 2004).
Recruitment relied on referrals from preschools, daycares, nursery schools, community
resources (clinics, physicians, and agencies), parent mailings, newspaper ads, and website
postings.
Exclusion criteria. Reasons for exclusion included current medication or behavioral
treatment for ADHD; a diagnosis of pervasive developmental disorder, psychosis, or
posttraumatic stress disorder; history of sexual or physical abuse; or any other psychiatric or
medical condition judged to contraindicate participation. Children with common mental health
diagnoses were not excluded.
Measures
Assessment schedule. All children were assessed at baseline (PRE) and post-treatment
(POST). WL participants obtained their treatment of choice after the POST assessments.
Children treated with NFPP and HNC were followed-up (F-UP) in October/November of the
next school year, when they were in a new class. The duration between POST and F-UP
assessments did not differ between the two treatments (M = 6.8 months, SD =2.01; range = 2.76
– 10.57 mo.).
All families were compensated $70 for each assessment visit. HNC parents received $15 per session to cover travel costs to the clinic. Assessments. Before treatment, assessments were made of ADHD and general
psychopathology in the primary caretaker, family characteristics and demographics. Outcome
measures were obtained at all three assessment points. (Study measures’ psychometric properties
are acceptable and are detailed in the on-line Supplemental Appendix.) Blinded outcome
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 10
assessors included clinicians, observers and teachers. To help assure that teachers were masked
to condition, parents were informed of the rationale and importance of not discussing their
child’s treatment with the teacher.
ADHD: Primary outcomes were teacher and parent ADHD ratings (Total, H/I and IN
subscale scores) on the Conners scales, applying published norms (T-scores) for 3-4-year-old
children. Both versions use a 4-point Likert scale. Non-primary ADHD outcomes were (i)
clinician ADHD ratings using the ADHD-Rating Scale-IV (Zhang, Faries, Vowles, &
Michelson, 2005), which assessed the 18 DSM-IV ADHD symptoms following a parent
interview. The number of symptoms with frequency and impairment ratings of at least “often”
and “moderate”, respectively, served as the outcome measure; and (ii) children’s levels of
sustained and focused attention and activity during a videotaped five-minute period while
playing with a standard multi-domain toy (“Play Park”) coded by observers using a validated
observational coding system. As per Sonuga-Barke et al. (2001), an “index of
attention/engagement” was calculated (time on task/total number of switches from zone to zone).
Oppositional and defiant symptoms: These were assessed with the preschool version of
the New York Teacher and Parent Rating Scales (NYTRS, Miller et al., 1995; NYPRS, Brotman,
Kamboukos & Theise, 2008). Both scales assess symptoms of oppositional defiant disorder and
conduct disorder, and include identical Defiance and Physical Aggression subscales.
Delay of Gratification: This was assessed with the Delay of Gratification-Cookies Delay
Task (Campbell, Pierce, March, Ewing, & Szumowski, 1994). Each child was asked to wait for a
signal (clap) before taking a treat (an M&M candy) placed under one of three upturned cups.
Eight trials were given in a pseudo-random order with delays of between 5 and 30 s. The
experimenter’s hands are raised at the midpoint (i.e., after 10s if the delay was 20s) ready to clap.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 11
A child’s score on each trial indicates his level of inhibition (0 = not inhibited: the child lifts the
cup and takes the M&M; 1 = partially inhibited: during the delay, the child makes a movement
toward the cup but makes no attempt to take the M&M; 2 = fully inhibited: the child is able to
wait and gets the M&M at the end of the delay, after the clap). Based on parental requests, for
some children (n=37), a nonedible reward (a small “fuzzy bear”) was used instead of M&Ms (see
on-line Appendix for details).
Parenting Practices and Functioning: A composite score reflecting parent-reported
positive parenting practices (e.g., clear expectations, appropriate discipline) was generated from
three subscales of the Parenting Practice Interview (PPI; Webster-Stratton, 1998).
The Global Impressions of Parent Child Interactions–Revised (GIPCI–R; Brotman,
Calzada, & Dawson-McClure, 2003) was used to make global ratings of parenting behavior
during a 15-min semi-structured play interaction that increased in structure and parent
directedness (i.e., free play, 7-min; puzzle task, 5-min; clean-up, 3-min). At the end of each
segment, independent observers masked to condition assessed seven aspects of parenting (i.e.,
“valence”, “responsiveness”, “warmth”, “use of praise”, “enjoyment”, “ use of scaffolding” and
“effectiveness”) on the GIPCI-R 5-point rating scale. Reliability analyses of the individual
ratings indicated that the “responsiveness” and “use of scaffolding” codes were insufficiently
reliable in themselves. However, the reliability of the total score across all seven codes was
acceptable (ICC =.54) (see on-line Appendix for additional details). Therefore, following
procedures used in previous trials, a composite score reflecting the average rating across the
seven subscales and three tasks served as the outcome measure (Brotman et al., 2011).
Parents completed the 16-item Parenting Stress Index-Short Form Revised (PSI-R;
Abidin, 1995) to evaluate parental distress, parent-child dysfunction and parent competence, and
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 12
four items from the Parent Perceptions of Parent Efficacy Scale (Hoover-Dempsey, Bassler, &
Brissie, 1992) to assess parental distress related to helping children succeed in school. The total
score from these 20 items served as the outcome measure.
Treatment satisfaction: Parents assigned to NFPP and HNC completed the Consumer
Satisfaction Questionnaire (CSQ; McMahon & Forehand, 2003) at POST. Parents indicated 1)
their overall satisfaction with treatment (1 = Very dissatisfied to 7 =Very satisfied), 2) the
perceived quality of services (1 = Poor to 7 = Superior), and 3) whether they would recommend
the treatment to a friend or relative with a preschooler with ADHD (1 = Strongly not recommend
to 7 = Strongly recommend). The sum of the three ratings served as the overall satisfaction index.
Interventions
New Forest Parenting Package (see on-line Appendix for detailed description). NFPP,
a manualized intervention for preschoolers with ADHD, involves 8 weekly 1-to-1.5-hour
sessions, delivered in the family home by trained clinicians. NFPP focuses on key issues related
to ADHD children’s functioning, and relies on the parent as the primary agent of change. While
it shares a number of features with standard BPT (i.e., management of problematic behavior
using behavioral techniques; promotion of authoritative parenting; increasing the quality and
quantity of positive and reciprocal parent-child interaction; reduction of parental negative
reactivity; and between-session “homework tasks” to facilitate improvement in specific parenting
techniques), it has a number of distinctive features. First, its home-based nature enables the
therapist to model play and behavioral strategies for the mother in the setting where the
behaviors are problematic. It also enables the therapist to address naturally occurring instances
of problematic child behaviors (e.g., difficulty waiting, inattention, dysregulation, etc.) that call
for the use of the parenting (and child) skills being taught. Sensitizing parents to the importance
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 13
of these “teachable moments” and of identifying and exposing their child to relevant real-world
situations where skills can be used provides numerous opportunities for skills development and
generalization.
Second, NFPP directly aims to improve four elements of constructive parenting: (i)
Scoping-- learning how to observe their child’s current level of competencies so as to promote
realistic expectations and performance goals for their child regarding self-control, attention, and
memory; (ii) Extending -- establishing new goals based on their child’s performance and
progress; (iii) Scaffolding-- using game-like activities to facilitate their child’s skills
development and goal achievement; and (iv) Consolidation—promoting their child’s skill use
across settings and situations to facilitate generalization.
Third, NFPP educates parents to alter their views of ADHD, avoid blaming their child for
ADHD symptoms, and increase parental tolerance with the ultimate goal of improving the
quality of the parent-child relationship.
Helping the Noncompliant Child. HNC is a manualized BPT intervention (McMahon
& Forehand, 2003) for treating young children with noncompliance and oppositional problems.
The individualized, clinic-based, treatment is delivered by therapists, with the parent and child
jointly, in each session. The clinical provision of HNC typically averages 8-10 intervention
sessions (McMahon & Forehand, 2003). To ensure that NFPP and HNC were equated for length
and amount of therapist contact, HNC was delivered in 8 weekly sessions, lasting approximately
one hour. HNC was provided according to the details specified in the McMahon and Forehand
(2003) treatment manual, except that a fixed number of sessions was conducted and meeting
behavioral criteria for advancement from one parenting skill to the next was not required.
HNC is based on social-learning theory and behavior modification principles and
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 14
methods and incorporates characteristics of the BPT model developed by Hanf (1969).
Treatment focuses on reducing noncompliance using a variety of methods to teach parents how
to change their maladaptive interaction patterns with their child. Specific program components
include: 1) modeling and parent role play, along with didactic instruction and discussion, to teach
parents the skills of attending, rewarding, ignoring, clear instructions and time out; and 2) home
practice, assignments and exercises, throughout the program.
The program includes two phases. Phase I focuses on differential attention. Parents are
taught how to attend to and describe their child’s appropriate behavior to the child (rather than
give commands, or teach), to provide rewards through positive physical attention (e.g., hugs) and
specific verbal praise, and to ignore their child’s minor, inappropriate attention-seeking
behaviors by not providing eye contact, nonverbal cues, verbal contact, or physical contact.
Phase II focuses on compliance training. Parents learn the importance of clear and simple
instructions, using a sequential approach to get their child’s attention to instructions and provide
positive rewards for compliance and negative consequences for non-compliance (i.e., Time-Out).
Treatment Delivery
Therapists (n=5) were clinical psychologists with at least two years of behavior therapy
experience with children and families. To control for possible therapist effects, each therapist
provided both treatments (Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009).
Therapists participated in face-to-face group training with the developers of each treatment, and
were supervised by them throughout the study through weekly group conference calls. A
modified Latin Square design was used to select videotapes for quality review. All treatment
sessions were videotaped and twelve percent were checked by an independent evaluator for
treatment fidelity and integrity, based on procedures developed and used previously by Abikoff
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 15
et al. (2013). The percentage of required therapeutic items covered served as an index of
fidelity. The integrity checklist assessed treatment contamination -- treatment spillover due to
therapist actions during a session (discussions, elaboration, or recommendations regarding
“prohibited” clinical elements that are specific to the non-assigned treatment).
Statistical Analyses
Linear mixed-effect models suitable for longitudinal data (Laird & Ware, 1982) were
implemented with R software (Bates, Maechler, Bolker, & Walker, 2013; R Core Team). The
outcome of interest at POST or F-UP was regressed on (1) baseline value of the same outcome
and (2) a factor encoding both time point and treatment condition (WL at POST, HNC at POST,
NFPP at POST, HNC at F-UP, or NFPP at F-UP), with a random subject effect to take within-
subject correlation into account. Overall treatment effect (difference among the three conditions)
at POST was tested by a likelihood ratio test, an approximate chi-square test with 2 df (Pinheiro
& Bates, 2000). All pairwise contrasts among the three treatments at POST, and the difference
between NFPP and HNC at F-UP were tested by approximate t-tests with a Satterthwaite
approximation to the denominator degrees of freedom (Verbeke & Molenberghs, 2009).
Maintenance of treatment effects was assessed by estimating change (F-UP minus POST)
averaged over NFPP and HNC (overall “time effect”); and difference in change between the two
treatments (time-by-treatment interaction).
In addition to missing data from 12 dropouts (described below), 15 children did not
participate in scheduled assessments, including one at POST (NFPP) and 14 at F-UP (4 NFPP,
10 HNC). In accordance with the intent-to-treat principle, data from all randomized participants
were analyzed according to their treatment assignment. Linear mixed-effect model inferences
remain valid under the “missing at random” assumption (Little & Rubin, 2002), meaning that
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 16
given the observed outcome values, dropout is conditionally independent of the subsequent
unobserved outcomes.
P-values reported here are unadjusted for multiple comparisons because (i) our aim was
to test a number of pre-specified hypotheses that relate to different aspects of the relative
efficacy of HNC and NFPP and (ii) we were especially concerned to minimize Type II error.
Given the dearth of information regarding NFPP’s effects in a clinical sample of preschool-aged
children, we deemed it important not to miss the opportunity to detect clinically meaningful
treatment effects.
Results
Sample
Recruitment occurred between 11/29/07 and 3/20/12. 164 preschoolers were randomized
(NFPP, n = 67; HNC, n = 63; WL, n = 34); 153 participants (93.3%) completed the study; eight
dropped out from NFPP (11.9%) and 4 from HNC (6.3%). Figure 1 is the participant flow chart
(CONSORT diagram).
The study sample was 73.8% male; 69.2% Caucasian, 16.4% African-American, 8.8%
Asian and 5.6% other; 25.6% of the participants were Hispanic. Children’s mean IQ was 101.8
(+14.8). DSM-IV ADHD subtype diagnoses were 50.6% Combined, 33.5% Hyperactive/
Impulsive, and 15.2% Inattentive; 41.5 % had a diagnosis of oppositional-defiant disorder and
6.7% had an anxiety disorder. 76.4% of mothers and 60.3% of fathers were college graduates.
The primary caregivers and informants were predominantly mothers (92.7%). No child started
medication from PRE to POST. At F-UP, three children in NFPP and three in HNC were
reported to have started medication. There were no significant group differences on any
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 17
demographic and clinical variables. The on-line Appendix contains complete demographic and
clinical characteristics.
Figure 1 Here
Treatment Attendance, Fidelity, Satisfaction and Harms
Attendance was equally high for each treatment (NFPP, M = 7.40 [SD +1.88]; HNC, M =
7.73 [+ 1.11]). Treatment fidelity was high (NFPP: 96.3%; HNC: 96.9%) and contamination was
low (0.6% of assessed NFPP and HNC sessions). Parents’ treatment satisfaction was equally
high for NFPP (19.98 +1.36) and HNC (19.78 +1.63).
It is conceivable that psychosocial treatment might be associated with iatrogenic effects
(e.g., tantrums, sad mood, irritability, anxiety) (Abikoff et al., 2013). As such, during training
and throughout the study, therapists were reminded to detect such occurrences and instructed to
report any concerns regarding possible AEs during weekly supervision. There were no adverse
effects with either NFPP or HNC. One WL participant dropped out because of worsening in
ADHD symptoms.
Treatment Differences at POST and F-UP
The treatment groups’ scores on all outcome measures at PRE, POST and F-UP are
presented in Table 1. Table 2 presents comparisons of adjusted outcomes at POST and F-UP.
We hypothesized that the specialized NFPP intervention would be superior to HNC, a
traditional behavioral program, in reducing ADHD symptoms.
ADHD Ratings
Parent ratings. POST. Contrary to expectations, parent ratings of inattention and
hyperactivity/impulsivity at POST were not significantly better for children who received NFPP
than HNC. However, as predicted for NFPP, and found as well for HNC, children in both
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 18
treatment groups were rated as less inattentive and hyperactive than those on the waiting list,
with large effects (all p < .001); (NFPP: Total, d = -1.01; IN, d = -.89; H/I, d = -.97; HNC: Total,
d = -1.24; IN, d = -1.09; H/I, d = -1.21) (Table 2).
F-UP. Improvement in attention was maintained by both treatment groups. In contrast,
Total ADHD and hyperactivity/impulsivity ratings worsened significantly in both treatments (p <
.03, and < .02, respectively), as reflected by the significant Time effects. Findings were contrary
to the hypotheses insofar as NFPP was not superior to HNC on any ADHD parental ratings at F-
UP; unexpectedly, children who received NFPP were rated worse on Total ADHD (p < .05, d =
.38) and hyperactivity/impulsivity (p < .04, d = .41) than children treated with HNC.
Teacher ratings. POST. At POST, no ADHD teacher rating yielded significant
advantage for NFPP over HNC or over Waitlist. All groups improved significantly over time.
F-UP. Outcomes at F-UP were identical to those at POST (Table 2).
Clinician ratings. POST. At the end of treatment, clinicians, who relied on parent reports
to evaluate children, did not consider children in NFPP to have fewer ADHD symptoms than
children in HNC. To the contrary, clinicians viewed children in NFPP as having significantly
more hyperactive/impulsive symptoms than children in HNC (p < .02, d = .61), but both
treatments were superior to Waitlist (all p <.001); (NFPP: Total, d = -1.66; IN, d = -1.27; H/I, d =
-1.07; HNC: Total, d = -2.20; IN, d = -1.47; H/I, d = -1.68) (Table 2).
F-UP. Clinician ratings showed no significant treatment differences in Total ADHD or
inattention symptoms; these remained stable in both groups from POST to F-UP. In contrast,
clinician ratings of hyperactivity/impulsivity symptoms decreased in the NFPP group and
increased in the HNC group, accounting for the significant Treatment x Time interaction (p <
.03, d = -.59) from POST to follow-up .
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 19
Tables 1 and 2 Here
Observed Attention and Ability to Delay
Sustained attention. There were no significant treatment differences in children’s
Attention/Engagement Index, or its components (Time on Task and Number of Switches) at POST
or F-UP (Table 2). Controlling for parental “interference” during task performance did not alter
the results.
Ability to delay. Edible and nonedible reward conditions yielded the same results and
were combined. No significant differences between treatments were obtained at POST or F-UP
(Table 2).
Oppositional and aggressive behaviors.
Parent ratings. POST. On the NYPRS, parent ratings of Defiance did not differentiate
children who received NFPP from those in HNC, but both treatment groups were significantly
superior to the Waitlist (p < .001) (NFPP, d = -.59; HNC, d = -.69). A different pattern emerged
for ratings of Physical Aggression; while NFPP and HNC were indistinguishable, children in the
HNC group, but not those in NFPP, were rated better than children on the Waitlist (p < .004, d =
-.37) (Table 2).
F-UP. At F-UP the groups’ Defiance and Physical Aggression scores were not
significantly different, and remained stable from POST to F-UP.
Teacher ratings. POST. Teacher ratings of Defiance and Physical Aggression on the NYTRS
did not differ significantly as a function of treatment condition.
F-UP. Children in the two treatments did not obtain significantly different Defiance or
Physical Aggression ratings at F-UP. The significant Time effect for Defiance (p <.01) reflects
that, over time, ratings for children in both groups became significantly lower.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 20
Parenting behaviors
Parenting practices. POST. On the PPI, parents in NFPP did not show superior
parenting practices than parents in the HNC group, and compared to WL, parents in both
treatments had significantly improved practices (p < .001) (NFPP, d = 1.20; HNC, d = 1.37)
(Table 2).
F-UP. At F-UP, parenting practices did not differ as a function of treatment. Parenting
practices did not deteriorate over time, but remained stable.
Observed Parenting. POST. Here again, NFPP did not lead to a significant advantage in
parenting behaviors. The significant Treatment effect (p< .001) reflects that parents in the HNC
group had significantly better GIPCI-R scores than parents in both the NFPP (p < .003, d = -.57)
and WL (p < .001, d = .97) groups, which did not differ from each other (Table 2).
F-UP. At F-UP, parenting behavior scores for the NFPP and HNC treatment groups did
not differ significantly. The significant Time effect (p < .005) is due to an overall worsening of
GIPCI-R observed parenting behaviors over time, in both treatment groups.
Parenting stress. POST. Treatment with NFPP did not differentially reduce stress, as
rated by parents. Rather, NFPP and WL parents did not differ significantly, and the significant
Treatment effect (p <.002) reflects that parents in the HNC condition improved significantly
more than parents in NFPP (p < .03, d = .30), and Waitlist (p < .001, d = -.58).
F-UP. At F-UP, the advantage for HNC was no longer significant.
Discussion
Replicating findings from previous trials using community samples (Sonuga-Barke et al.,
2001; Thompson et al., 2010), the current study found that, compared to controls, NFPP
improved preschoolers’ symptoms of ADHD and oppositionality when outcomes were based on
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 21
parent reports (either directly or via clinicians). Notably, although the magnitude of the effect
sizes for NFPP for ADHD symptoms was large, the impact of these effects on functioning is
unclear given that the group’s mean ADHD T-scores on the CPRS-R were still in the clinical
range at the end of treatment. More important, these parent-reported effects were not
corroborated by direct observations, nor by teachers, both masked to condition. By integrating
constructive parenting approaches, behavior management procedures and scaffolding techniques,
NFPP was designed to enhance the child’s development of attention and impulse control,
particularly the ability to delay. The results from preschoolers meeting ADHD diagnostic criteria
do not support the claim that NFPP addresses the dysfunctions underlying ADHD, and in turn,
alters the underpinning processes that lead to change in ADHD symptoms. The failure to
demonstrate differential improvements on the delay task is especially telling in this regard.
In contrast to parental reports, there were no differential improvements on any teacher-
rated outcome. This failure to corroborate parent ratings of therapeutic effects on core ADHD
symptoms with independent measures is consistent with a recent meta-analysis that found no
effects of behavioral interventions when analyses were restricted to studies using blinded
measures of ADHD symptom change (Sonuga-Barke et al., 2013), and to the extensive ADHD
psychosocial treatment literature documenting difficulties in achieving setting generalization
(Abikoff, 2009; Hinshaw, Klein, & Abikoff, 2007).
There are a number of non-exclusive possible explanations for the discrepant effects
across home and school. First, that parents, aware of treatment allocation and invested heavily in
its delivery, over-estimated the effects of treatment. Second, that the intervention changed
parents’ perceptions of ADHD symptoms, perhaps making parents more tolerant and thus
causing them to provide less severe ratings, in spite of there being no real improvement in the
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 22
child’s behavior itself. Third, that NFPP had real effects at home, but these did not transfer to
school. It is commonly accepted that to facilitate generalization, behaviors learned in one setting
(e.g., home) have to be supported and contingently rewarded in non-treatment settings at the
“point of performance” (e.g., school) (Rajwan et al., 2012); and neither NFPP nor HNC targets
school behavior.
Although HNC has been used clinically with children with ADHD (McMahon &
Forehand, 2003), to our knowledge this is the first RCT to evaluate HNC in preschoolers who
met diagnostic criteria for ADHD. Overall the pattern of effects was similar to, but somewhat
more effective, than those seen for NFPP. As was the case for NFPP, reductions in parent-
reported ADHD and conduct problems indicate that HNC may be useful in addressing disruptive
behaviors at home in preschoolers with ADHD. However, once again, these positive effects did
not transfer to school settings. Parental reinforcement of compliance may have indirectly
facilitated children’s attention to parental instructions. However, HNC addressed non-
compliance but did not specifically target ADHD behaviors, yet it had effects on parent ratings
of ADHD. This pattern of treatment effects for HNC suggests that improved ratings of ADHD
were due to rater bias effects, and to changes in parental perception, perhaps linked to halo-
effects (e.g., Abikoff et al., 1993), and/or to the reductions in parental stress reported by HNC
parents (Oord, Prins, Oosterlaan, & Emmelkamp, 2006).
Some behavioral gains were sustained after treatment. The stability in clinician-rated
ADHD symptoms from POST to F-UP replicates Sonuga-Barke et al.’s (2001) report of
maintenance of NFPP treatment effects on clinicians’ ADHD symptom ratings, based on
information provided by parents. Contrary to prediction, however, with the exception of
clinician ratings of hyperactivity/impulsivity symptoms, no behavioral outcome at follow-up
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 23
favored NFPP over HNC, which suggests that NFPP is not associated with sleeper effects, and
does not result in a subsequent consolidation of behavioral skills that leads to differential
development over time. In fact, HNC was superior to NFPP on several ADHD parent outcomes
at follow-up. Because HNC did not target ADHD behaviors, this finding seems difficult to
explain. It is possible that HNC was more effective at bringing about fundamental changes in
parents’ views of their children’s difficult behavior. However, a more straightforward
explanation is that HNC’s relative superiority reflects a fall-off in gains with NFPP, as post-hoc
analyses of parents’ ADHD ratings indicated a significant increase in the severity of NFPP
children’s symptom scores from POST to F-UP.
The additional improvements in teacher ratings of ADHD symptoms and Defiance during
follow-up are difficult to interpret in light of the non-significant treatment effect at POST on
these measures and the lack of follow-up data on controls. Given the decrease in teacher-rated
problems in all three groups from PRE to POST, a parsimonious explanation is that the
improvement in NFPP and HNC at follow-up represents a general decrease in symptoms over
time in school, rather than a sleeper effect.
Parents’ self-ratings of positive parenting practices improved for both interventions. This
finding is in accord with a recent meta-analysis indicating that behavioral treatments for children
with ADHD have beneficial effects on parent functioning (Daley et al., 2014), and suggests that
NFPP and HNC may play a role in supporting parents of preschool children with ADHD.
However, HNC reduced parenting stress and improved observed parenting relative to both WL
controls and NFPP, but NFPP did not impact either domain. The absence of improvement in the
NFPP group of observed parenting, by raters masked to condition, replicates findings from a
previous NFPP trial (Thompson et al., 2009). This result is especially noteworthy given that the
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 24
observation protocol was sensitive to HNC intervention effects in the current trial and to two
other group-based BPT interventions with preschoolers evaluated in RCTs (Brotman, et al.,
2008; Brotman et al., 2011). This pattern of findings calls into question the ability of NFPP to
significantly alter parenting behaviors, especially relative to other BPT interventions.
Objective improvements in parenting with HNC have been reported in RCTs with
oppositional children based on observations of parent-child interactions at home (Peed, Roberts,
& Forehand, 1977) and in the clinic (Wells & Egan, 1988). It is possible that HNC’s emphasis
on differential attention and the use of time out procedures contribute to positive parenting
effects, not only for parents of oppositional preschoolers, but also for those of children with
ADHD.
The trial had several limitations. Interpretation of maintenance effects is not definitive
because of the lack of a control group during follow-up. Non-adjustment increases the risk that
at least one of the significant findings represents Type I error. In contrast to Sonuga-Barke et al.
(2001), but consistent with Thompson et al. (2009), there was no improvement on observed
attention during the Play Park task, a laboratory assessment of on-task behavior. It is possible
that differences in task duration (5 minutes in the current and Thompson et al. studies vs. 10-
minutes in the Sonuga-Barke et al. trial) contributed to the failure to replicate the initial findings.
Indeed, at baseline, approximately 75% of the children in the current study were on-task for the
entire task, suggesting that ceiling effects may have diminished the opportunity to detect possible
treatment differences. The ecological validity and clinical relevance of the study’s “objective”
laboratory measures are uncertain. Because high behavioral variability is a hallmark of ADHD,
a single laboratory assessment may not capture the child’s typical behavior. Moreover, the
relationship between performance on laboratory analog tasks and functioning in real-world
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 25
settings is often poor (Toplak, West, & Stanovich, 2013). The inclusion of multiple, blinded
observations of the child’s behavior at home might address some of the limitations associated
with the use of parent ratings and laboratory measures. The percentage of treatment sessions that
should be reviewed to ascertain treatment integrity and inform on a study’s internal validity has
not been established. However, the 12% independently reviewed in the current study is lower
than that recommended by Perepletchikova (2014). Approximately two-thirds of the parents had
a college or graduate degree. Whether the results reported here apply to children with less well-
educated parents is uncertain. Finally, the 8-week treatment duration, corresponding to the
original NFPP manualized protocol, is relatively brief. It is unknown whether a longer treatment
period, with a more intensive focus on parental scaffolding would yield greater benefits.
In summary, notwithstanding its limitations, the strengths of this trial, including a clinical
sample of preschoolers meeting DSM-IV criteria for ADHD, the collection of teacher ratings,
high treatment fidelity and integrity, and the inclusion of an active treatment comparator,
increase confidence in the study results.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 26
Key points
• Traditional behavioral parent training (BPT) programs have limited effects on ADHD
symptoms of preschool children with ADHD.
• An RCT evaluated the New Forest Parenting Package (NFPP) (a home-based program
reported to improve ADHD-related behaviors in community preschoolers) in a clinical
sample using parent, teacher and laboratory measures, compared to “Helping the
Noncompliant Child” (HNC), an evidence-based BPT comparator, and Wait-list controls.
• NFPP was not superior to, and in some cases less effective than, HNC. Both treatments
improved non-blind parent ratings of ADHD but not objective teacher and laboratory
measures of ADHD.
• Maintenance effects were obtained for some non-blind parent-reported outcomes, particularly
for HNC.
• The findings indicate that NFPP does not result in generalized change in ADHD and
document difficulties in achieving generalization across non-targeted settings.
Acknowledgments
This research was supported by National Institute of Mental Health Grant 5R01MH074556 to
Howard Abikoff (PI). We would like to acknowledge the assistance of Robyn Stotter, the
project coordinator (now at Motives Group, New York, NY); Christina Di Bartolo, the primary
research assistant; the study therapists, Melanie Fernandez (now at the Child Mind Institute, New
York, NY), Jennifer Rosenblatt, Janna Stein (now working as a school psychologist), Andrea
Vazzana, and Timothy Verduin; the independent evaluator, Elizabeth Hume (currently
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 27
unaffiliated); and the clinical evaluators, Jamie Furr (now at Boston University), Andy Pham
(now at Florida International University) and Stephanie Wagner. We also thank the observer
trainers, David Daley (at the University of Nottingham UK) and Francoise Acra (now at
University of Hawai’i at Manoa); Kathleen Kiely Gouley (now practicing in Norwalk, CT) for
her assistance during the preparation of the NFPP manual; Patrick Shrout (NYU Department of
Psychology) for his contribution during the preparation of the grant application; and Eva Petkova
NYU Department of Child and Adolescent Psychiatry) for her statistical consultation.
Correspondence to
Howard Abikoff, The Child Study Center at NYU Langone Medical Center, One Park Avenue,
New York, NY 10016, USA; Tel: (646) 574-4934; Fax: (646) 754-5209; E-mail:
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 28
References
Abidin, R. R. (1995). Manual for the parenting stress index. Odessa, FL: Psychological
Assessment Resources.
Abikoff, H. (2009). Commentary. ADHD psychosocial treatments: Generalization reconsidered.
Journal of Attention Disorders, 13, 207-210. doi:10.1177/1087054709333385
Abikoff, H. B., Vitiello, B., Riddle, M. A., Cunningham, C., Greenhill, L. L., Swanson, J. M., ...
& Wigal, T. (2007). Methylphenidate effects on functional outcomes in the preschoolers
with attention-deficit/hyperactivity disorder treatment study (PATS). Journal of Child and
Adolescent Psychopharmacology, 17(5), 581-592. doi:10.1089/cap.2007.0068
Abikoff, H., Courtney, M., Pelham Jr, W. E., & Koplewicz, H. S. (1993). Teachers' ratings of
disruptive behaviors: The influence of halo effects. Journal of Abnormal Child
Psychology, 21(5), 519-533. doi:10.1007/BF00916317
Abikoff, H., Gallagher, R., Wells, K. C., Murray, D. W., Huang, L., Lu, F., & Petkova, E.
(2013). Remediating organizational functioning in children with ADHD: Immediate and
long-term effects from a randomized controlled trial. Journal of Consulting and Clinical
Psychology, 81(1), 113. doi:10.1037/a0029648
American Academy of Pediatrics. (2011). Clinical practice guideline: ADHD: Clinical practice
guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity
disorder in children and adolescents. Pediatrics, 128(5) 1007-1022.
doi:10.1542/peds.2011-2654
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 29
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: Author.
Anderson, T., Ogles, B., Patterson, C., Lambert, M., & Vermeersch, D. (2009). Therapist effects:
facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical
Psychology, 65(7), 755-768. doi:10.1002/jclp.20583
Barkley, R. A., Shelton, T. L., Crosswait, C., Moorehouse, M., Fletcher, K., Barrett, S., ... &
Metevia, L. (2000). Multi‐method psycho‐educational intervention for preschool children
with disruptive behavior: Preliminary results at post‐treatment. Journal of Child
Psychology and Psychiatry, 41(3), 319-332. doi:10.1111/1469-7610.00616
Bates, D., Maechler, M., Bolker, B., & Walker, S. (2013). lme4: Linear mixed-effects models
using Eigen and S4. R package version 1.0-5. http://CRAN.R-project.org/package=lme4
Bor, W., Sanders, M. R., & Markie-Dadds, C. (2002). The effects of the Triple P-Positive
Parenting Program on preschool children with co-occurring disruptive behavior and
attentional/hyperactive difficulties. Journal of Abnormal Child Psychology, 30(6), 571-
587. doi:10.1023/A:1020807613155
Brotman, Calzada, & Dawson-McClure, (2003). Global Impressions of Parent–Child
Interactions. Unpublished assessment instrument.
Brotman, L.M., Calzada, E., Huang, K.Y., Kingston, S., Dawson-McClure, S., Kamboukos, D.,
… & Petkova, E. (2011). Promoting effective parenting practices and preventing child
behavior problems in school among ethnically diverse families from underserved, urban
communities. Child Development, 82 (1), 258-276. PMID: 1291441
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 30
Brotman, L.M., Gouley, K.K., Huang, K.Y., Rosenfelt, A., O’Neal, C., Klein, R.G., Shrout, P.
Preventive intervention for preschoolers at high risk for antisocial behavior: Long-term
effects on child physical aggression and parenting practices. (2008). Journal of Clinical
Child and Adolescent Psychology, 37, 386 - 396. PMID: 18470775
Brotman, L.M., Kamboukos, D., Theise, R (2008). Symptom-specific measures for disorders
usually first diagnosed in infancy, childhood, or adolescence. In A.J. Rush, M.B. First, &
D. Blacker (Eds.), Handbook of Psychiatric Measures (pp. 309-342), 2nd ed.
Washington, DC: American Psychiatric Publishing, Inc.
Campbell, S. B., Pierce, E. W., March, C. L., Ewing, L. J., & Szumowski, E. K. (1994). Hard‐to‐
manage preschool boys: Symptomatic behavior across contexts and time. Child
Development, 65(3), 836-851. doi:10.1111/j.1467-8624.1994.tb00787.x
Charach, A., Carson, P., Fox, S., Ali, M. U., Beckett, J., & Lim, C. G. (2013). Interventions for
preschool children at high risk for ADHD: A comparative effectiveness review.
Pediatrics, 131(5), 1584-1604. doi:10.1542/peds.2012-0974
Connell, C. M., & Prinz, R. J. (2002). The impact of child-care and parent–child interactions on
school readiness and social skills development for low-income African American
children. Journal of School Psychology, 40(2), 177–193. doi:10.1016/S0022-
4405(02)00090-0
Conners, C. K., Sitarenios, G., Parker, J. D., & Epstein, J. N. (1998b). The revised Conners'
Parent Rating Scale (CPRS-R): Factor structure, reliability, and criterion validity. Journal
of Abnormal Child Psychology, 26(4), 257-268. doi:10.1023/A:1022602400621
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 31
Conners, C. K., Sitarenios, G., Parker, J. D., & Epstein, J. N. (1998a). Revision and
restandardization of the Conners Teacher Rating Scale (CTRS-R): Factor structure,
reliability, and criterion validity. Journal of Abnormal Child Psychology, 26(4), 279-291.
doi:10.1023/A:1022602400621
Daley, D., Sonuga‐Barke, E. J. S., & Thompson, M. (2003). Assessing expressed emotion in
mothers of preschool AD/HD children: Psychometric properties of a modified speech
sample. British Journal of Clinical Psychology, 42(1), 53-67.
doi:10.1348/014466503762842011
Daley, D., van der Oord, S., Ferrin, M., Danckaerts, M., Doepfner, M., Cortese, S., & Sonuga-
Barke, E.J.S., on behalf of the European ADHD Guidelines Group (2014). Behavioral
interventions in Attention-Deficit/Hyperactivity Disorder: A meta-analysis of
randomized controlled trials across multiple outcome domains. Journal of the American
Academy of Child and Adolescent Psychiatry, 53(8), 835–847. doi:
10.1016/j.jaac.2014.05.013
DeWolfe, N. A., Byrne, J. M., & Bawden, H. N. (2000). Preschool inattention and impulsivity-
hyperactivity: Development of a clinic-based assessment protocol. Journal of Attention
Disorders, 4(2), 80-90. doi:10.1177/108705470000400202
Greenhill, L. L., Posner, K., Vaughan, B. S., & Kratochvil, C. J. (2008). Attention deficit
hyperactivity disorder in preschool children. Child and Adolescent Psychiatric Clinics of
North America, 17(2), 347-366. doi:10.1016/j.chc.2007.11.004
Greenhill, L., Kollins, S., Abikoff, H., McCracken, J., Riddle, M., Swanson, J., ... & Cooper, T.
(2006). Efficacy and safety of immediate-release methylphenidate treatment for
Met opmaak: Nederlands (België)
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 32
preschoolers with ADHD. Journal of the American Academy of Child and Adolescent
Psychiatry, 45(11), 1284-1293. doi:10.1097/01.chi.0000235077.32661.61
Hanf, C. (1969). A two stage program for modifying maternal controlling during mother-child
(M-C) interaction. Paper presented at the meeting of the Western Psychological
Association, Vancouver, British Columbia.
Hinshaw, S. P., Klein, R. G., & Abikoff, H. B. (2007). Childhood attention-deficit/hyperactivity
disorder: Nonpharmacological treatments and their combination with medication. In P. E.
Nathan, & J. M. Gorman (Eds.), A guide to treatments that work (pp. 3–27), 3rd ed. New
York: Oxford University Press.
Hoover-Dempsey, K. V., Bassler, O. C., & Brissie, J. S. (1992). Explorations in parent-school
relations. The Journal of Educational Research, 85(5), 287-294. doi:
10.1080/00220671.1992.9941128
Lahey, B. B., Pelham, W. E., Loney, J., Lee, S. S., & Willcutt, E. (2005). Instability of the DSM-
IV subtypes of ADHD from preschool through elementary school. Archives of General
Psychiatry, 62(8), 896. doi:10.1001/archpsyc.62.8.896
Lahey, B. B., Pelham, W. E., Stein, M. A., Loney, J., Trapani, C., Nugent, K., ... & Baumann, B.
(1998). Validity of DSM‐IV attention‐deficit/hyperactivity disorder for younger children.
Journal of the American Academy of Child and Adolescent Psychiatry, 37(7), 695-702.
doi:10.1097/00004583-199807000-00008
Laird, N. M., & Ware, J. H. (1982). Random-effects models for longitudinal data. Biometrics 38,
963-974.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 33
Little, R. J. A., & Rubin, D. B. (2002). Statistical Analysis with Missing Data. New York: J.
Wiley & Sons.
McMahon, R. J., & Forehand, R. (2003). Helping the noncompliant child: Family-based
treatment for oppositional behavior (2nd ed.). New York: Guilford Press.
Merrell, K. W., & Wolfe, T. M. (1998). The relationship of teacher‐rated social skills deficits
and ADHD characteristics among kindergarten‐age children. Psychology in the Schools,
35(2), 101-110. doi:10.1002/(SICI)1520-6807(199804)35:2<101::AID-PITS1>3.0.CO;2-
S
Miller, L. S., & Kamboukos, D. (2000). Symptom-specific measures for disorders usually first
diagnosed in infancy, childhood, or adolescence. AJ Rush, HA Pincus, MB First, & LE
McQueen and others (Task Force). Handbook of Psychiatric Measures, 325-356.
Miller, L. S., Klein, R. G., Piacentini, J., Abikoff, H., Shah, M. R., Samoilov, A., & Guardino,
M. (1995). The New York teacher rating scale for disruptive and antisocial behavior.
Journal of the American Academy of Child and Adolescent Psychiatry, 34(3), 359-370.
doi:10.1097/00004583-199503000-00022
National Institute for Health and Clinical Excellence. (2008). Attention deficit hyperactivity
disorder: Diagnosis and management of ADHD in children, young people and adults.
(Clinical guideline 72).
Oord, A., Prins, P. J. M., Oosterlaan, J., & Emmelkamp, P. M. G. (2006). The association
between parenting stress, depressed mood and informant agreement in ADHD and ODD.
Behaviour Research and Therapy, 44(11), 1585-1595. doi:10.1016/j.brat.2005.11.011
Met opmaak: Nederlands (België)
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 34
Peed, S., Roberts, M., & Forehand, R. (1977). Evaluation of the effectiveness of a standardized
parent training program in altering the interaction of mothers and their noncompliant
children. Behavior Modification, 1(3), 323-350. doi: 10.1177/014544557713003
Perepletchikova, F. (2014). Assessment of treatment integrity in psychotherapy research. In L.M.
Hagermoser Sanetti & T.R. Kratochwill (Eds.), Treatment integrity: A foundation for
evidence-based practice in applied psychology (pp. 131-158). Washington, D.C.: American
Psychological Association.
Pinheiro, J. C., & Bates, D. M. (2000). Mixed-Effects Models in S and S-PLUS. New York:
Springer.
Rajwan, E., Chacko, A., & Moeller, M. (2012). Nonpharmacological interventions for preschool
ADHD: State of the evidence and implications for practice. Professional Psychology:
Research and Practice, 43(5), 520. doi:10.1037/a0028812
R Core Team (2013). R: A language and environment for statistical computing. R Foundation for
Statistical Computing, Vienna, Austria. URL http://www.R-project.org/.
Riddle, M.A., Yershova, K., Lazzaretto, D., Paykina, N., Yenokyan, G., Greenhill, L., Abikoff,
H., … and the PATS Study Group. The Preschool Attention-Deficit/Hyperactivity
Disorder treatment study (PATS) 6-year follow-up. (2013). Journal of the American
Academy of Child & Adolescent Psychiatry, 52, 250-263. doi:
10.1016/j.jaac.2012.12.007.
Semel, E., Wiig, E. H., & Secord, W. A. (2004). Clinical Evaluation of Language Fundamentals,
fourth edition – Screening Test (CELF-4 Screening Test). Toronto: The Psychological
Corporation.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 35
Shaffer, D., Fisher, P., Lucas, C. (1998). NIMH DISC-IV Diagnostic Interview Schedule for
Children, Parent-Informant. New York: Columbia University.
Sonuga‐Barke, E. J., & Halperin, J. M. (2010). Developmental phenotypes and causal pathways
in attention deficit/hyperactivity disorder: potential targets for early intervention?. Journal
of Child Psychology and Psychiatry, 51(4), 368-389. doi:10.1111/j.1469-
7610.2009.02195.x
Sonuga-Barke, E. J., Brandeis, D., Cortese, S., Daley, D., Ferrin, M., Holtmann, M., ... &
Sergeant, J. (2013). Nonpharmacological interventions for ADHD: Systematic review
and meta-analyses of randomized controlled trials of dietary and psychological
treatments. American Journal of Psychiatry, 170(3), 275-289.
doi:10.1176/appi.ajp.2012.12070991
Sonuga-Barke, E. J., Daley, D., Thompson, M., Laver-Bradbury, C., & Weeks, A. (2001).
Parent-based therapies for preschool attention-deficit/hyperactivity disorder: A
randomized, controlled trial with a community sample. Journal of the American
Academy of Child and Adolescent Psychiatry, 40(4), 402-408. doi:10.1097/00004583-
200104000-00008
Sonuga‐Barke, E. J., Oades, R. D., Psychogiou, L., Chen, W., Franke, B., Buitelaar, J., ... &
Faraone, S. V. (2009). Dopamine and serotonin transporter genotypes moderate
sensitivity to maternal expressed emotion: the case of conduct and emotional problems in
attention deficit/hyperactivity disorder. Journal of Child Psychology and Psychiatry,
50(9), 1052-1063. doi:10.1111/j.1469-7610.2009.02095.x
Met opmaak: Nederlands (België)
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 36
Sonuga-Barke, E. J., Thompson, M., Abikoff, H., Klein, R., & Brotman, L. M. (2006).
Nonpharmacological interventions for preschoolers with ADHD: The case for specialized
parent training. Infants & Young Children, 19(2), 142-153.
Sonuga-Barke, E.J.S., Thompson, M., Daley, D., & Laver-Bradbury, C. (2004). Parent training
for pre-school Attention-Deficit/Hyperactivity Disorder: Is it effective as part of routine
primary care? British Journal of Clinical Psychology, 43, 449-457.
Thompson, M. J., Laver-Bradbury, C., Ayres, M., Le Poidevin, E., Mead, S., Dodds, C., ... &
Sonuga-Barke, E. J. (2009). A small-scale randomized controlled trial of the revised new
forest parenting programme for preschoolers with attention deficit hyperactivity disorder.
European Child and Adolescent Psychiatry, 18(10), 605-616. doi:10.1007/s00787-009-
0020-0
Toplak, M. E., West, R. F., & Stanovich, K. E. (2013). Do performance‐based measures and
ratings of executive function assess the same construct? Journal of Child Psychology and
Psychiatry, 54(2), 131-143. doi:10.1111/jcpp.12001
Verbeke, G. & Molenberghs, G. (2009). Linear Mixed Models for Longitudinal Data. New York:
Springer.
Volkow, N. D. & Insel, T. R. (2003). What are the long-term effects of methylphenidate
treatment? Biological Psychiatry, 54(12), 1307–1309.
doi:10.1016/j.biopsych.2003.10.019
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 37
Wacharasin, C., Barnard, K. E., & Spieker, S. J. (2003). Factors affecting toddler cognitive
development in low-income families: Implications for practitioners. Infants & Young
Children, 16(2), 175–181.
Webster-Stratton, C. (1998). Preventing conduct problems in Head Start children: Strengthening
parent competencies. Journal of Consulting and Clinical Psychology, 66(5), 715–730.
doi:10.1037/0022-006X.66.5.715
Webster-Stratton, C. H., Reid, M. J., & Beauchraine, T. (2011). Combining parent and child
training for young children with ADHD. Journal of Clinical Child and Adolescent
Psychology, 40(2), 191-203. doi:10.1080/15374416.2011.546044
Wechsler, D. (2002). Wechsler Preschool and Primary Scale of IntelligenceTM Third Edition
(WPPSITM-III). Sydney, NSW: Pearson.
Wells, K. C., & Egan, J. (1988). Social learning and systems family therapy for childhood
oppositional disorder: Comparative treatment outcome. Comprehensive Psychiatry,
29(2), 138-146. doi: 10.1016/0010-440X(88)90006-5
Zhang, S., Faries, D. E., Vowles, M., & Michelson, D. (2005). ADHD Rating Scale IV:
Psychometric properties from a multinational study as a clinician-administered
instrument. Internal Journal of Methods in Psychiatric Research, 14(4), 186-201.
doi:10.1002/mpr.7
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 38
61 Completed Treatment
6 Parents Dropped: schedule
changed; family moved
59 Completed Treatment
4 Parents Dropped: schedule
changed
Figure 1 Participant Flow Chart
164 Randomized
150 Excluded
110 Did not meet criteria for CPRS and/or
CTRS
18 Did not meet DSM-IV ADHD criteria on
Clinical Evaluation
7 Did not meet criteria on the CELF
13 Failed to meet other inclusion criteria
(i.e. parent schedule flexibility, teacher
consent, etc.)
905 Patients Screened By Telephone
578 Excluded - Phone Screen Fail (wrong age,
too far away, scheduling will not work, not in
school, exclusionary diagnosis, , etc.)
327 Underwent Screening Assessment
67 Assigned to NFPP
67 included in ITT Post
treatment analyses
55 Completed Y2 F-UP
67 included in ITT Y2 F-UP
analyses
63 Assigned to HNC
63 included in ITT Post
treatment analyses
49 Completed Y2 F-UP
63 included in ITT Y2 F-UP
analyses
34 Assigned to Wait List
33 Completed Waiting Period
1 drop after 4 weeks due to
teacher’s concern for child’s
safety
34 Included in ITT Post
treatment analyses
13 Enrolled as Training Cases
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 39
Legend for Figure 1
CPRS = Conners Parent Rating Scale; CTRS = Conners Teacher Rating Scale; CELF = Clinical
Evaluation of Language Fundamentals; NFPP = “New Forest Parenting Package”; HNC =
“Helping the Noncompliant Child”; ITT = intent-to-treat; Y2 = year two; F-UP = follow-up
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 40
Table 1 Raw Scores of Study Outcome Measures at Pre, Post, and Follow-up
NFPP (N = 67) HNC (N = 63) WL (N = 34)
PRE POST F-UP PRE POST F-UP PRE POST *
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
ADHD Ratings
CPRS-Total-
75.42 11.43 65.26 12.15 68.01 11.69 75.21 9.49 62.62 11.05 63.44 10.13 78.01 9.17 76.44 9.84
CPRS-IN-
72.91 12.08 63.6 11.60 65.60 13.53 72.75 11.50 60.47 11.57 61.74 10.04 76.39 9.68 75.31 10.38
CPRS-H/I-
74.56 8.38 64.62 12.00 68.08 10.69 74.36 9.45 62.32 10.34 63.39 10.24 75.88 9.10 74.45 10.67
CTRS-Total-
76.73 9.26 68.46 11.41 64.27 12.27 74.67 7.92 68.10 9.95 62.06 11.39 75.96 9.94 70.65 11.22
CTRS-IN-
73.97 11.35 65.12 12.26 61.39 13.58 72.55 9.21 64.93 11.50 60.48 11.79 71.94 12.28 68.22 11.81
CTRS-H/I-
75.63 8.87 68.31 11.17 64.25 11.64 73.74 10.36 67.57 10.32 62.01 12.06 75.78 10.26 70.26 11.98
Clinician-Rated, Total Sx-
12.4 2.79 8.28 4.22 8.00 4.89 12.7 2.47 6.92 4.41 7.58 3.65 13.03 2.38 12.85 2.92
Clinician-Rated, IN Sx-
5.63 1.99 3.39 2.38 3.61 2.79 5.89 2.24 3.02 2.67 3.30 2.34 6.15 1.52 6.12 2.25
Clinician-Rated, H/I Sx-
6.78 1.63 4.89 2.43 4.39 2.66 6.81 1.63 3.90 2.61 4.28 2.51 6.88 1.67 6.73 1.68
ADHD Tasks
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 41
Candy Delay- Total+
13.36 3.72 14.07 3.83 14.26 3.16 13.30 3.70 14.31 3.12 14.52 3.28 12.75 4.14 13.45 3.97
Play Park- Time on Task+
4.78 .55 4.77 .65 4.79 0.56 4.80 .61 4.49 1.17 4.92 0.36 4.73 .54 4.54 1.15
Play Park- # of Switches-
7.41 3.48 7.83 3.05 8.12 3.64 7.96 4.33 8.38 3.31 8.02 3.91 8.28 4.28 7.58 3.28
Play Park- Engagement Index+
.92 .90 .71 .35 0.85 0.82 .79 .46 .66 .39 0.81 0.52 .75 .56 .75 .43
Opposition/Aggression
NYPRS-Defiance-
1.31 .65 .84 .52 .95 .57 1.24 .62 .75 .49 .82 .60 1.17 .80 1.10 .72
NYPRS-Aggression-
.57 .63 .43 .55 .30 .37 .61 .81 .34 .46 .32 .39 .63 .88 .58 .76
NYTRS-Defiance-
1.39 .81 .90 .69 .79 .81 1.21 .86 .98 .76 .62 .63 1.00 .75 .82 .77
NYTRS-Aggression-
.94 .99 .61 .76 .61 .90 .74 .90 .47 .67 .35 .72 .65 .89 .47 .60
Parenting Ratings
PPI- Total+
3.69 0.41 3.97 0.37 3.98 0.39 3.67 0.33 4.01 0.33 4.01 0.36 3.90 0.35 3.65 0.52
PSI-R Total-
2.31 0.58 2.12 0.53 2.10 0.54 2.52 0.54 2.08 0.44 2.11 0.62. 2.51 0.63 2.44 0.70
Parenting Observation
GIPCI-R Total+
3.44 0.44 3.61 0.43 3.52 0.47 3.52 0.44 3.89 0.44 3.66 0.55 3.51 0.43 3.45 0.47
Abbreviations: CTRS-R, CPRS-R= Conners Rating Scale-Revised (P= parent, T= teacher); NYPRS, NYTRS= New York Rating Scale (P= parent, T= teacher); PPI=
Parenting Practices Interview; PSI= Parenting Stress Index; GIPCI= Global Impression of Parent Child Interactions; - lower score is better,
+ higher score is
better
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 42
Table2 Comparison of adjusted outcomes at post-treatment and follow-up
Post Follow-Up *
Treatment
Effect
NFPP v WL HNC v WL NFPP v HNC
Treatment
Effect
Time
Treatment X
Time
��� p p db p db p db p db p db p db
ADHD Ratings
CPRS- Total-
32.79 .001 .001 -1.01 .001 -1.24 ns 0.23 .047 0.38 .023 0.20 ns 0.15
CPRS- IN-
30.85 .001 .001 -0.89 .001 -1.09 ns 0.19 ns 0.30 ns 0.14 ns 0.11
CPRS- H/I-
31.40 .001 .001 -0.97 .001 -1.21 ns 0.24 .033 0.41 .012 0.23 ns 0.17
CTRS- Total-
1.47 ns ns -0.28 ns -0.23 ns -0.05 ns 0.12 .001 -0.53 ns 0.16
CTRS- IN-
2.48 ns ns -0.33 ns -0.25 ns -0.07 ns 0.00 .005 -0.39 ns 0.07
CTRS- H/I-
0.76 ns ns -0.18 ns -0.15 ns -0.03 ns 0.08 .001 -0.48 ns 0.10
Clinician-Rated, Total Sx-
41.97 .001 .001 -1.66 .001 -2.20 .051 0.54 ns 0.19 ns 0.03 ns -0.36
Clinician-Rated, IN Sx-
35.11 .001 .001 -1.27 .001 -1.47 ns 0.20 ns 0.21 ns 0.12 ns 0.01
Clinician-Rated, H/I Sx-
31.23 .001 .001 -1.07 .001 -1.68 .014 0.61 ns 0.02 ns -0.08 .024 -0.59
ADHD Tasks
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 43
Candy Delay- Total+
1.35 ns ns 0.18 ns 0.19 ns -0.01 ns -0.09 ns 0.03 ns -0.08
Play Park- Time on Task+
1.60 ns ns 0.46 ns 0.04 ns 0.42 ns -0.17 .040 0.44 ns -0.59
Play Park- Number of Switches-
2.44 ns ns 0.07 ns 0.24 ns -0.17 ns 0.14 ns -0.03 ns 0.31
Play Park- Engagement Index+
0.48 ns ns -0.08 ns -0.14 ns 0.05 ns 0.02 ns 0.23 ns -0.04
Opposition/ Aggression
NYPRS- Defiance-
23.24 .001 .001 -0.59 .001 -0.69 ns 0.10 ns 0.06 ns 0.11 ns -0.05
NYPRS- Aggression-
9.18 .010 ns -0.17 .003 -0.37 ns 0.20 ns -0.01 ns -0.05 ns -0.21
NYTRS- Defiance-
2.27 ns ns -0.17 ns 0.01 ns -0.19 ns -0.05 .009 -0.28 ns 0.14
NYTRS- Aggression-
0.12 ns ns -0.01 ns -0.05 ns 0.03 ns 0.14 ns -0.08 ns 0.11
Parent Ratings
PPI- Total+
45.71 .001 .001 1.20 .001 1.37 ns -0.17 ns -0.27 ns 0.00 ns -0.10
PSI-R Total-
12.84 .002 ns -0.28 .001 -0.58 .026 0.30 ns .10 ns -0.01 ns -0.20
Parenting Practices-Observed
GIPCI-R Total+
19.34 .001 ns 0.40 .001 0.97 .003 -0.57 ns -0.26 .005 -0.40 ns 0.31
Note. - lower score is better,
+ higher score is better. Abbreviations: CTRS-R, CPRS-R= Conners Rating Scale-Revised (P= parent, T= teacher); NYPRS, NYTRS=
New York Rating Scale (P= parent, T= teacher); PPI= Parenting Practices Interview; PSI-R= Parenting Stress Index; GIPCI-R= Global Impression of Parent Child
Interactions-Revised; aTwo-tailed tests; bEffect sizes (Cohen’s d) are the differences between adjusted scores at post-treatment, divided by the standard
deviation at baseline, p-values are model-based
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 44
On-line Supplemental Appendix
This appendix provides supplementary information regarding demographics of the study
sample (Table A1); psychometric characteristics and other details regarding the study outcome
measures; additional details regarding the NFPP intervention; and when participants dropped
out of treatment. References for citations noted in the Appendix are provided as well.
Measures
ADHD-RS-IV. The scale has demonstrated treatment sensitivity and has acceptable
psychometric properties, including internal consistency (Cronbach's alpha = 0.86); one-week
test-retest reliability (ICC = .76); convergent validity (correlation with Conners Parent Rating
Scale ADHD Index = .79), and discriminant validity (differentiates between children with
Inattentive and Combined ADHD subtypes [p’s < .001]) (Faries, Yalcin, Harder, & Heiligenstein,
2001; Zhang, Faries, Vowles, & Michelson, 2005).
Play Park observational coding system. The coding system has adequate test-retest
(Pearson r = 0.81) and inter-rater reliability (Pearson r = 0.76) and discriminates between ADHD
and normal preschoolers (Sonuga-Barke et al., 2001).
New York Teacher and Parent Rating Scales (NYTRS and NYPRS). The scales have
adequate psychometric properties (Collette, Ohan, & Myers, 2003), including internal
consistency and test-retest reliability (Brotman, Kamboukos & Theise, 2008), discriminative
validity (Miller et al., 1995) and sensitivity to treatment effects (Brotman et al., 2008; Klein et al.,
1997).
Delay of Gratification-Cookies Delay Task. The task is reliable and discriminates
between hard-to-manage preschoolers and their peers (Campbell, Pierce, March, Ewing, &
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 45
Szumowski, 1994).
Thirty-seven of the parents did not consent to using an edible reward (M&Ms) with their
children for the Delay Task. For these participants, a nonedible reward (a small “fuzzy bear”)
was used instead of M&Ms. Separate analyses of children who participated in the edible and
nonedible reward conditions yielded the same results; therefore, the data from the two reward
subgroups were combined and the results for the whole sample are reported in the paper.
We also administered a Choice Delay Task and intended to combine children’s
scores on this task with their Cookie Delay Task scores to generate a Delay Aversion
Index, (DAI; Sonuga-Barke, Dalen, & Remington, 2003). However, because the children
experienced problems with this task, including misunderstanding the instructions and
being distracted by the reward stickers during the Choice Delay, the scores on this task
were insufficiently valid for analyses.
GIPCI-R. The GIPCI-R subscale scores have been reported to have adequate inter-rater
reliability and correlate significantly with parent ratings of global symptoms, hyperactivity and
aggressive behavior (Brotman, Gouley, Chesir-Teran, Dennis, & Klein, 2005). In the current
study, although the individual subscale scores were not sufficiently reliable, the ICC for the Total
score across all subscales was acceptable (.54, CI = .48 - .60). In addition, factor analyses of the
seven subscales yielded a one-factor solution with internal consistency (alpha coefficient) of .83.
These results provide further support for using a composite Total score, which reflects the
quality of positive parenting characteristic of the individual GIPCI subscales.
NFPP Intervention
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 46
Constructive parenting. NFPP combines behavior management techniques with
therapeutic components targeted directly at increasing constructive parenting (CP). NFPP
focuses on promoting parental behaviors associated with four elements of CP. (i) Scoping –
evaluating through observation and ongoing interactions their child’s developmental
competencies to help the parent establish a “baseline” and a realistic set of expectations for
their child’s performance. (ii) Extending - setting a proximal developmental goal for their child
that is sufficiently challenging to represent a developmental gain and sufficiently achievable,
with parental help and encouragement, so as not to undermine the child’s sense of self-efficacy
and positive attributional style. (iii) Scaffolding – using motivating game-like activities to provide
support, encouragement and structures to help their child achieve developmental gains by
meeting the proximal goals set by the parent across various domains (i.e. self-control, attention
and memory). (iv) Consolidation - working to consolidate their child’s performance at a given
developmental level before establishing new goals and extending performance further.
Consolidation also involves teaching the child to apply developing skills to related domains to
facilitate generalization. To this end, parents are taught to use the same label when framing
tasks in related domains; for example, turn taking, patience, coping with frustrating events, are
all referred to by the parents as waiting tasks.
Examples of training basic processes. As noted above, in the context of play with their
child, parents use a variety of games to facilitate the development of key underlying processes.
These play settings are augmented by teachable moments that provide the child with additional
opportunities to practice the same skill sets in other situations. The following are three
examples of the type of games parents use in NFPP.
Auditory memory and listening skills are augmented using a game called “I went to the
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 47
market and bought…“ . This turn taking game begins with the parent saying “I went to the
market and bought a loaf of bread”. The child has to say the same thing and add one other item
to the list of items bought, The parent repeats the two item list and adds a third item, which the
child then has to repeat while adding another item, etc. The number of items to remember are
gradually increased based on the child’s performance. Teachable moments might entail the
parent mentioning to the child items that need to be bought at the store, asking the child to try
and remember these items, and then when they are in the store asking the child if he/she can
remember which items they need to buy.
“I spy”, a game that can be played outside the home, places demands on memory,
attention, and inhibitory processes. The goal for the child is to “spy out” (be on the lookout for)
an object with certain characteristics, and only when the child sees it to point it out to the
parent. As the child improves, the number of characteristics of the object the child is on the
lookout for would gradually increase from one (e.g., “something yellow”, “a ball”), to two (e.g.
“a yellow car”, “something that is red that daddy might wear”), and could increase further,
based on the child’s performance (e.g., “a yellow car with a lady driver”).
“Kim’s game”, intended to facilitate attention and visual memory, starts with the parent
placing two items on a tray, having the child look at them and then covering up the items. The
parent asks the child to remember what the items are and where they are on the tray. The
parent increases the number of items gradually, as the child gets better at recalling the items
and their placement.
Daily Diary. Parents are taught to use a Daily Diary to indicate when (day, time, nature
of situation) and what they did during “teachable moments” to facilitate targeted skills building
and practice in their child. Therapists reviewed the Diary with the parent at the outset of each
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 48
home-based session, and provided positive feedback, clarification and problem-solving, as
appropriate.
Dropouts
There were 8 dropouts in NFPP (one dropped before the first session, five after completing
either 1, 2, 3, 4, or 7 sessions, and two after completing 6 sessions), and 4 dropouts in HNC (one
each after 2, 3, 4, or 6 sessions).
References
Brotman, L. M., Gouley, K. K., Chesir-Teran, D., Dennis, T., & Klein, R. G. (2005). Prevention for
preschoolers at high risk for conduct problems: Immediate outcomes on parenting
practices and child social competence. Journal of Clinical Child and Adolescent
Psychology, 34(4), 724-734.
Brotman, L. M., Kamboukos, D., & Theise, R. (2008). Symptom-specific measures for disorders
usually first diagnosed in infancy, childhood, or adolescence. In J.A. Rush, Jr. (Ed.),
Handbook of psychiatric measures, 2nd ed. (pp.309-342). Arlington, VA: American
Psychiatric Publishing, Inc.
Campbell, S. B., Pierce, E. W., March, C. L., Ewing, L. J., & Szumowski, E. K. (1994). Hard-to-
manage preschool boys: Symptomatic behavior across context and time. Child
Development, 65(3), 836-851.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 49
Collette, B. R., Ohan, J. L., & Myers, K. M. (2003). Ten-year review of rating scales. VI: Scales
assessing externalizing behaviors. Journal of the American Academy of Child and
Adolescent Psychiatry, 42(10), 1143-1170.
Faries, D. E., Yalcin, I., Harder, D., & Heiligenstein, J. H. (2001). Validation of the ADHD Rating
Scale as a clinician administered and scored instrument. Journal of Attention Disorders,
5(2), 107-115.
Klein, R. G., Abikoff, H., Klass, E., Ganeles, D., Seese, L. M., & Pollack S. (1997). Clinical efficacy of
methylphenidate in Conduct Disorder. Archives of General Psychiatry, 54(12), 1073-
1080.
Miller, L. S., Klein, R. G., Piacentini, J., Abikoff, H., Shah, M. R., Samoilov, A., & Guardino, M.
(1995). The New York teacher rating scale for disruptive and antisocial behavior. Journal
of the American Academy of Child and Adolescent Psychiatry, 34(3), 359-370.
Sonuga-Barke, E. J., Dalen, L., & Remington, B. (2003). Do executive deficits and delay aversion
make independent contributions to preschool attention-deficit/hyperactivity disorder
symptoms? Journal of the American Academy of Child and Adolescent Psychiatry, 42(11),
1335-1342.
Sonuga-Barke, E. J., Daley, D., Thompson, M., Laver-Bradbury, C., & Weeks, A. (2001). Parent-
based therapies for preschool attention-deficit/hyperactivity disorder: A randomized,
controlled trial with a community sample. Journal of the American Academy of Child and
Adolescent Psychiatry, 40(4), 402-408.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 50
Zhang, S., Faries, D. E., Vowles, M., & Michelson, D. (2005). ADHD Rating Scale IV: Psychometric
properties from a multinational study as a clinician-administered instrument. Internal
Journal of Methods in Psychiatric Research, 14(4), 186-201.
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 51
Table A1 Baseline Demographics and Clinical Characteristicsa
Variable Total (N = 164) NFPP (N = 67) HNC (N= 63) WL (N = 34)
Child Demographics
Age (years), mean (SD) 3.57 (0.5) 3.58 (0.5) 3.57 (0.5) 3.56 (0.5)
Sex Male 73.8% 73.1% 76.2% 70.6%
Race/Ethnicity
African American 16.4% 20.0% 12.9% 15.6%
White 69.2% 64.6% 69.4% 78.1%
Other 14.4% 15.4% 17.7% 6.3%
Hispanic 25.6% 29.2% 26.2% 21.9%
Child Clinical Characteristics
WPPSI IQ, mean (SD) Verbal 103.3 (16.21) 102.5 (15.3) 103.1 (18.3) 102.4 (18.2)
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 52
Performance 100 (15.46) 102.9 (16.4) 98.5 (15.5) 97.8 (15.5)
Full 101.8 (14.84) 103.2 (13.5) 101.2 (15.4) 100.2 (16.6)
CELF, mean (SD) 9.74 (2.4) 9.55 (2.1) 10.1 (2.7) 9.46 (2.0)
DSM-IV ADHD Diagnosis
Inattentive 15.3% 11.9% 17.5% 17.6%
Hyperactive/Impulsive 33.7% 35.8% 31.7% 32.4%
Combined 50.9% 50.7% 50.8% 50%
Comorbidity, N (%)
Oppositional-defiant disorder 41.5% 49.3% 39.7% 29.4%
Anxiety disorderb 6.7% 7.5% 3.2% 11.8%
Enuresis-Encopresis 3.0% 6.0% 0.0% 2.9%
Other 1.2% 1.5% 1.6% 0.0%
Special Servicesc 52.4% 47.8% 50.8% 64.7%
Parent/Family Demographics
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 53
High school graduated
Mother 7 (4.3%) 2 (3.0%) 3 (4.8%) 2 (6.1%)
Father 22 (14.1%) 9 (14.1%) 10 (16.1%) 3 (10.0%)
Some colleged
Mother 34 (20.9%) 17 (25.4%) 9 (14.3%) 8 (24.2%)
Father 45 (28.8%) 17 (26.6%) 10 (16.1%) 8 (26.7%)
College graduated
Mother 48 (29.4%) 21 (31.3%) 20 (31.7%) 7 (21.2%)
Father 47 (30.1%) 18 (28.1%) 20 (32.3%) 9 (30.0%)
Advanced graduate/ Professional degreed
Mother 69 (42.3%) 23 (34.3%) 31 (49.2%) 15 (45.5%)
Father 47 (30.1%) 17 (26.6%) 20 (32.3%) 10 (33.3%)
Employed
Mother 109 (67.7%) 49 (73.1%) 41 (65.1%) 19 (57.6%)
Father 129 (82.7%) 51 (76.1%) 53 (85.5%) 25 (83.3%)
Married 125 (77.6%) 50 (74.6%) 51 (81.0%) 24 (77.4%)
Parent Clinical Characteristicse
Running head: PARENT TRAINING FOR PRESCHOOL ADHD 54
Adult Assessment of ADHD, mean (sd)f
Inattentive s(x) count 1.28 (2.09) 1.36 (2.15) 1.34 (2.22) 1.03 (1.71)
Inattentive Severityg 1.76 (1.00) 1.80 (1.08) 1.71 (0.90) 1.81 (1.03)
Hyperactive s(x) count 0.58 (1.60) 0.98 (1.86) 0.74 (1.38) 0.79 (1.43)
Hyperactive/Impulsive Severityg 1.42 (0.84) 1.62 (1.02) 1.26 (0.69) 1.35 (0.70)
Current Symptom Scale, mean (sd)h ADHD Normed Total Score 44.52 (9.75) 45.01 (9.68) 44.56 (10.27) 43.38 (9.10)
Brief Symptom Inventory, mean (sd)i 50.91 (9.67) 49.11 (9.16) 51.54 (9.55) 53.24 (10.49)
Abbreviations: WPPSI, Wechsler Preschool and Primary Scale of Intelligence; CELF, Clinical Evaluation of Language Fundamentals.
aPercentages based on data available; bIncludes Separation Anxiety, General Anxiety, Social Phobia, and Specific Phobia; cIncludes Early Intervention Services,
Head Start, etc.; dHighest Education Level completed (not all parents responded); eParent who participated in study treatment; fMannuzza, S., Klein, R. G., &
Castellanoes, F. X. (2004). Assessment of Adult Attention Deficit Hyperactivity Disorder [Instrument, administration, and scoring information]. Unpublished
instrument. Retrieved from http://www.aboutourkids.org/Research/Research_Publications/Proal_et_al_2011; gSeverity scores ranged from 1 (none), 3,
(moderate) and 5 (extreme); hBarkley, R. A., & Murphy, K. R. (2006). Attention-deficit hyperactivity disorder: A clinical workbook (Vol. 2). Guilford Press.;
iDerogatis, L. R., & Spencer, P. M. (1993). Brief Symptom Inventory: BSI. Upper Saddle River, NJ: Pearson.